research

The impact of the BASNEF

educational programme on
breastfeeding behaviour in Iran
Abstract
This study examines the impact of an educational programme on the
breastfeeding attitudes and behaviour of pregnant women. It is a casecontrol study of 100 pregnant women in two hospitals affiliated to
Shiraz University of Medical Sciences. The samples were randomly
divided into a case and control group. The study looked at the effects
of an educational programme based on the BASNEF model, which is a
simplified approach to understanding behaviour focused on the beliefs,
attitude, subjective norms and enabling factors of participants. The
model was applied initially and after four educational sessions mothers
behaviour towards breastfeeding was analysed. The results were analysed
using statistical tests. The independent t-test showed that there were
significant differences in the awareness mean score, mothers perceptions
of behaviour results, the score of attitudes towards working and the
mean score of immediate enabling factors post-educational intervention,
and at one and four months post-intervention (p<0.0001). The scores of
subjective norms between the two groups was only significant for the
medical staff (p=0.031). Compared with traditional education, modelbased learning has been found to have a positive impact on improving
behaviour; therefore, it is suggested that it should be employed in the
clinical education of medical teams, especially midwives.

Marzieh Akbarzadeh
Faculty Member for
Midwifery, Shiraz
University of Medical
Sciences
Nasrin Bahmani
Health Centre Midwife
Shiraz University of
Medical Sciences
Marzieh Moatari
Associate Professor of
Nursing and Midwifery
Shiraz University of
Medical Sciences
Saeede PourAhmad
Associate Professor
of Biostatics, Shiraz
University of Medical
Sciences

276

o ciety requires healthy and happy

people in order to achieve development;
human milk is the best source of
nutrition and a strong immunological factor
to help babies fight infections (Landrigan et
al, 2002). Therefore, the role of breastfeeding
is important to future health and can
lower the risk of certain illnesses, such as
allergic diseases (Kull et al, 2002), diarrhoea,
respiratory infections (Nakamori et al, 2010),
diabetes, bowel diseases, celiac and chronic
liver diseases (Ivarsson et al, 2002), and cancers
including lymphoma and breast cancer (Shu
et al, 1995). Breastfeeding has also been shown
to increase childrens cognitive development,
leading to better development of the brain,
and prevention of mental and emotional
problems (Siskind et al, 1989; Rogan, 1993).
The benefits of breastfeeding have been widely
acknowledged for many years (World Health
Organization (WHO), 1998; WHO and UNICEF,
2003), and breastfeeding rates in some countries

reflect this. Between 1992 and 1998, rates of

breastfeeding up to 6 months postpartum
increased by 64% in Sweden, 45% in Germany,
25% in Denmark and 27% in the USA (Earle et
al, 2002; Li et al, 2008). While in Iran, a 2009
study found that breastfeeding continuation
rates at 6, 12, 18 and 24 months were 98, 92, 76
and 0.97%, respectively (Rakhshani et al, 2009).
However, influenced by certain factorssuch as
poor literacy, urbanisation, separation of mother
and child, lack of support, false beliefs of parents,
working mothers and cultural background (PrezEscamilla, 1995; Prez-Escamilla, 1996; Visness,
1997)many mothers stop breastfeeding earlier
than the recommended 6 months, replacing
it with alternative and supplementary feeding.
This can imply irreversible physical, mental,
economic and social damages to communities
(Earle et al, 2002; Li et al, 2008).
A study by Dennis (2002) showed that
few mothers in developed countries continue
breastfeeding over three months. Despite
the interest and preference of mothers to
choose breastfeeding, there are few who
continue with it for as long as the infant
requires (Walker et al, 2000). For example,
the Islamic faith emphasises the importance
of breastfeeding (Raisler et al, 1999); yet, as a
Muslim country Irans exclusive breastfeeding
rates decreased from 44% in 2000 to 27% in
2004 (Veghari G et al, 2011); and the mean
of exclusive breastfeeding duration in the
country was found to be 5.59 months, with
rates for 5 and 6 months at 83.8 and 66.4%,
respectively (Veghari et al, 2011). The duration
of breastfeeding in South-Asian countries
such as Bangladesh (Mannan et al, 1995) and
India (Rajaretnam, 1994) are reported to be at
28.2 and 18.4 months, respectively. In England
and Wales, breastfeeding for at least 6 months
is recommended (Boyer, 2012), but studies
have found that women from lower economic
social groups have less intention to breastfeed
their babies (Spiby et al, 2009).
The most important factors in breastfeeding
are subjective norms, such as the fathers, friends
British Journal of Midwifery April 2013 Vol 21, No 4

research
and medical professionals perceptionsall
of which are crucial in the prevalence and
continuation of breastfeeding. Stewart-Knox et
als (2003) study in Northern Ireland indicated
that improper social norms make successful
breastfeeding harder for mothers, and suggests
a social approach in educational programmes.
Tarkka et al (1999) also reported that social
support is very important for successful
breastfeeding, especially the fathers support
at home, which can influence the mothers
decision in the early stages after childbirth
(Tarkka et al, 1999). Numerous studies on
successful breastfeeding factors show that
those mothers who are socially and emotionally
supported feel more encouraged to breastfeed
successfully (Matich et al, 1992; Li et al, 1999;
Barona-Vilar et al, 2009).
Different Iranian and international studies
on the impact of successful breastfeeding
have revealed the positive impact of education
(Hoyer et al, 1998; Hoyer et al, 2000; Kull et
al, 2002; Kim, 2009) but few studies have
examined this subject systematically using
educational theories. By using behavioural
theories in educational interventions,
the BASNEF model has the potential for
efficacy. The model centres on four different
factorsBeliefs, Attitudes, Subjective Norms
and Enabling Factors (BASNEF) (Salehi et
al, 2004)and is designed to observe and
record behaviour, identifying the factors
that influence beliefs and decision-making
to positively change the behaviour of the
participant (Lancaster et al, 2000). Belief
and attitude cover the positive or negative
evaluation of behaviour; subjective norms
demonstrate ones belief relative to influential
persons, social pressures and ref lections;
while enabling factors are skills and
sources that allow the persons aim or
intention to change their behaviour (Sharifirad
et al, 2011). Therefore, in educational
interventions this model could give a
potential capacity for the effectiveness of
educational interventions (Hazavehei et
al, 2008a). In this study, an educational
intervention based on the BASNEF model
was applied to boost mothers awareness
of breastfeeding and improve their attitude
towards its importance. The intervention
provided them with sufficient information
and access to medical staff for consultation
and collaboration, while detecting subjective
norms to improve the breastfeeding behaviour
of pregnant women.
British Journal of Midwifery April 2013 Vol 21, No 4

Aim
The studys objective was to measure the
impact of an educational programme, based
on the BASNEF model, on the breastfeeding
behaviours of pregnant women, who had been
referred to prenatal clinics affiliated to the
Shiraz University of Medical Sciences.

Methods
The study is a semi-experimental and
prospective intervention. The sample consisted
of mothers who were under the care of the
selected educational clinics affiliated with
Shiraz University of Medical Sciences and
were in the third trimester (4136 weeks) of
their pregnancy. This period is often the most
challenging because mothers are usually more
concerned with the approaching birth and
fetuses are more intuitive (Newfield, 2012). The
sample size was defined to be 50 for each group
using sample calculation and comparison of the
average of two groups (control and case groups),
based on previous results (=0.05, =0.2, p=0.8).

Participants
The sample was selected randomly. The
first person was subject to the educational
intervention group based on the inclusion
criteria and the second put in the control group.
Participants in both groups had to meet the
following characteristics:
Mothers
ll First pregnancy and without complications
ll Pregnancy gestational age of 3641 weeks
ll Aged between 18 and 35
ll Minimum education of third grade in junior

high school
ll Free of any obvious and serious mental or

physical diseases during the study

ll Resident in Shiraz
ll Intention to feed their babies with their
own milk
ll Voluntary participation in the research project
ll Completed the consent form.
Infants
ll Should have been exclusively breastfed,

healthy at birth and singleton

ll Free of any obvious congenital abnormalities

Data collection
If the participant met the inclusion criteria
and gave consent, pre- and post-intervention
questionnaires based on the BASNEF model
from 36 weeks were provided by the researcher.
277

research
Table 1. Comparable age, education and occupation of women
and their partners in the control group and the BASNEF group
BASNEF group

Control group

p-values

Mean SD age of wife

23.864.30

24.24.18

0.786

Mean SD age of husband

28.165.2

28.962.89

0.617

Education

Primary school
educated

32%

26%

0.852

Secondary
school educated

54%

54%

Higher
education

14%

20%

Housekeeper

96%

98%

Employed

4%

2%

100%

100%

Primary school
educated

38%

36%

0.801

Secondary
school educated

46%

50%

Higher
education

16%

14%

Job
Partner employed
Partners
education

Table 2. Attitudes towards pregnancy in mother and partner

BASNEF group
Yes

Control group
No

Yes

No

No.

No.

No.

No.

Mothers
willingness for
pregnancy

48

96%

4%

49

98%

2%

Partners
willingness for
pregnancy

46

92%

8%

48

96%

4%

Parents who
have seen
relatives
breastfeed

48

96%

4%

47

93%

7%

The questionnaire included questions on

demographics (9), knowledge (6), evaluation
of results (5), attitudes (10), intention (1),
factors for capability (10) and subjective norms
(5). All the questions were answered by the
mothers before the educational intervention.
The awareness questions included 12 multiple
choice questions (with three possible
answers), with the correct answer given 1
point, and I dont know and wrong answers
given 0 points. After their awareness was
assessed, mothers were divided into five
groups: very weak, weak, moderate, good and
very good. The evaluation questions included
five multiple choice questions (with three
278

possible answers); again, the correct answer

was given 1 point, and I dont know and wrong
answers given 0 points. Attitude questions
included 10 multiple choice questions (with
five possible answers) of Likert Scale ranging
between 4 (the best answer) and 0 points. The
behavioural intention question was multiple
choice, with six possible answers, and scored
between 5 (the best answer) and 0 points.
The enabling factor questions were seven yes/
no questions with a score of 1 for yes and 0
for no. The questions on subjective norms
to determine who influenced breastfeeding
behaviour included five multiple choice
questions (with six possible answers) and
the answers were calculated as frequencies.
All the scores were calculated out of 100 to
facilitate the comparison. The questionnaire
was designed by Dr Gholamreza Sharifirad,
based on research using the instructional
BASNEF model on maternal breastfeeding
behaviour, and the scoring method based
on Likert scales. Content validity was
confirmed by experts who were academic staff
and health educators. The reliability of the
questionnaire was determined by Cronbachs
Alpha in a pilot study performed upon 20
participants who were not included in the
survey. Cronbachs Alpha was calculated for
the awareness questions (=0.81), attitude
(=0.9), performance (=0.78), enabling
factors (=-.82) and subjective norms (=0.91)
(Sharifirad et al, 2010). The interventions
were designed as four educational sessions
of 90 minute lectures for one month. The
behavioural objectives were determined for
each session and run via different methods
including lectures, educational images, group
discussions, question and answer sessions,
or by using pamphlets, CDs and PowerPoint
based on the BASNEF model. The mothers were
given an educational booklet on breastfeeding,
an educational CD and a letter of introduction
to visit medical staff for consultation. The
questionnaires were completed by mothers
immediately after the interventions, and
one and three months post-educational
interventions. The educational interventions
were evaluated during the first until third
month via phone calls to mothers and review
classes. The researchers phone number was
given to the mothers so they could call about
any problems with breastfeeding around the
clock and be consulted if necessary. The
control group received routine education at
pregnancy clinic postnatal.
British Journal of Midwifery April 2013 Vol 21, No 4

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Table 3. Breastfeeding intention
Before intervention
Very
much

pvalue

Much

No.

No. %

BASNEF group

44

88% 6

12% 0.741

Control group

46

92% 4

8%

Analysis of the data

The data were controlled, encoded and then
analysed using SPSS with Paired Sample test,
Repeated Measurement Analysis, MC-Nemar
and t-test, and Chi-square test

Results
The mean age of the mothers in the BASNEF
group was 23.864.30 and in a control group it
was 24.24.18. At baseline in both educational
and control groups for the frequency distribution
of age, education and occupation of pregnant
mothers and their partners (Table 1). Pregnancy
intention for the mother and the spouse, and
if they had seen relatives breastfeeding were
also evaluated, being similar in this respect
(Table 2). The independent t-test showed that
there was not any significant difference between
the control and BASNEF educational groups
before educational intervention on awareness
mean score (p=0.427), mothers evaluation of
behaviour results (p=0.741), attitude toward
work (p=0.890), and mean scores of enabling
factors (p=0.948) while there was a significant
difference between the two groups immediately
after the educational intervention, one month
and three months post-intervention in all four
areas (p < 0.00010) (Table 3).
The MC-Nemar test showed that there was
a significant difference in educational group
between subjective norms at pre- and posteducational intervention about the medical
staff (p=0.031) and there was no significantly
different relationship for mother compliance,
mother-in-law and friends (p 0.05) (Table 4).

Discussion
Utilising methods to improve the process of
childrens development is on the agenda of
health operational programmes and one of
the most important objectives of health care
programmes across the globe (Soleimani et al,
2010). Holding training programmes based on
theory and education models could be effective
in improving the attitude and behaviour of
mothers towards exclusive breastfeeding
(Dewan et al, 2002).
280

The results showed that the awareness mean

score before the intervention in the educational
group was 58.1414.48 and 55.7214.7 in the
control group. The awareness mean score
after the intervention in the educational
group was 97.164.32 and 61.0514.06 in the
control group. The result of the paired t-test
showed that the awareness mean score after the
educational intervention increased significantly
in the intervention group (p<0.0001) while no
significant change in the control group was
observed (p=0.063), indicating the educational
interventions effect on the mothers awareness
based on the BASNEF model. This result is not in
line with those of the studies carried out based
on the BASNEF model (Hazavehei et al, 2008b).
The relative increase in the control groups
scores could be considered as curiosity because,
in the pre-test, mothers asked the medical staff
and relatives for the correct answers. Mothers
awareness score at one month post-intervention
was 94.095.14 and three months later was
91.846.54. The repeated measures test showed
that the difference remained significant over
time (p<0.0001) which is inconsistent with the
results of Matvienko et als (2001) study in which
the difference had remained significant after 16
months. The results of this study are consistent
with the findings from Dewan et als study (2002)
to determine the knowledge and attitudes of
teenage mothers about prenatal breastfeeding
education. Additional studies have indicated
the effect of education as positive (Lutter et
al, 1997), while some studies have found it not
to be effective (Clark et al, 1995; Curro et al,
1997). The mothers evaluation of behaviour
results immediately after the intervention were
97.28.09; at one month post-intervention were
88.421.03; and three months post-intervention
were 9021.47. The repeated measures test
showed that the difference remained significant
over time (p<0.0001). It implies the effectiveness
of intervention based on the BASNEF model
in the areas of faith and persistence, retention
and promotion of mothers attitude about the
importance of breastfeeding for infants.
The repeated measures test showed that
there was a significant difference (p<0.0001)
in attitude between the two groups when
they were recorded immediately after the
intervention, and at one and three months.
These results are consistent with Raman
et als (2006) study on patients attitude
on retinopathy and its post-education
improvement in India. The results reveal
that using a logical messaging system while
British Journal of Midwifery April 2013 Vol 21, No 4

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Table 4. The mean score of knowledge, evaluation of behaviour, attitude towards practice, enabling
factors at any time in the BASNEF group and the control group

Knowledge

Evaluation of behaviour

Attitude

Enabling factors

Before the
intervention

Immediately after One month after Three

months
the intervention
the intervention
a f te r
the
intervention

Mean

SD

Mean

SD

Mean

SD

Mean

SD

BASNEF

58.14

14.48

97.16

4.32

94.09

5.14

91.84

6.54

Control

55.72

14.7

61.05

14.06

58.14

14.37

57.44

6.54

T-test result

0.427

BASNEF

64.8

21.96

97.2

8.09

88.4

21.03

90

21.47

Control

63.6

13.21

64.4

13.57

62.8

22.5

80.4

24.4

T-test result

0.741

BASNEF

3.09

0.43

3.31

0.36

3.29

0.28

3.27

0.26

Control

3.08

0.42

3.09

0.37

3.08

0.33

3.04

0.32

T-test result

0.89

BASNEF

31.19

23.26

96.28

7.53

94.04

8.75

95.23

7.98

Control

30.90

21.09

35.56

20.64

39.13

19.84

40.99

20.33

T-test result

0.948

applying theories of behavioural change in

educational programmes could be effective on
behaviour and attitude. A study on educational
intervention concluded that there was not any
significant change in the attitude score to the
act in subjects (Hazavehei et al, 2009). This
could be due to the fact that usually attitude
and performance are influenced more than
awareness by a number of environmental and
social factors (Linden, 1991); thus, education
and information alone could not reform
attitudes. Scott et al (2004: 125) state: Maternal
and paternal infant feeding attitudes are often
stronger predictors of both choice of feeding
method and duration of breastfeeding than
sociodemographic factors; therefore, attitude
is important. Kuan et al (1999: 1) state:
Successful exclusive breastfeeding mothers
reported that the visiting nurse watched
them breastfeed and [advised them] to call
or visit family and friends with concerns
about breastfeeding, all of which are factors in
their success.
I n questions about enabling factor,
a significant difference was seen between
immediate, one and three month delayed
educational interventions in the group
(p<0.0001), indicating that breastfeeding skill
has a positive impact on the mothers support
and their consultation in continuation of
breastfeeding. The enabling factors could be
an effective facilitator to achieve intentions
to the given behaviour (Kuan et al, 1999). In
British Journal of Midwifery April 2013 Vol 21, No 4

0.000

0.000

0.000

0.000

0.003

0.000

0.000

0.03

0.002

0.000

0.000

0.000

this regard, a study by Yngve and Sjstrm

(2001) was carried out to examine the
impact of health education programmes on
continuation of breastfeeding across Europe,
which concluded that: One way of assuring
effective breastfeeding promotion would be
the creation of a comprehensive surveillance
system, for example, using the Precede
Proceed model with its four diagnostic steps,
especially targeting young, low-income, less
educated mothers. Yngve and Sjstrms (2001)
results are inconsistent with the findings of
this study.
LaVeist (1995) concluded that the enabling
factors could, in fact, act more importantly
than behavioural and cultural differences.
Meanwhile, Arora et als (1998) study
found that information on breastfeeding in
pregnancy classes and the media (enabling
factors) play an important role in the initiation
of breastfeeding.
In DiGirolamo et als (2003) study, a
great number of mothers (41%) were not
breastfeeding at 6 weeks postpartum because
a large proportion of physicians (61%) and
hospital staff (42%) were not perceived
as expressing a preference for a particular
feeding method. It is essential that there
should be many lectures and seminars on
breastfeeding regularly throughout the year
(Shealy et al, 2005).
The M C-Nemar test (Table 4) revealed
that there was no significant difference in
281

research
be acknowledged and encouraged (Sweet et
al, 2009: 540).

Key points
ll Exclusive breastfeeding rates for babies older than 6 months old in
Iran are decreasing
ll One factor that encourages successful breastfeeding is subjective
norms, which takes into account fathers, friends and medical
professionals views on breastfeeding
ll The BASNEF educational model can be implemented to alter
mothers behaviour towards breastfeeding
ll Participation of other family members is also a factor in successful
breastfeeding
ll The BASNEF education programme can be used by midwives and
health professionals to teach pregnant women about the benefits
of breastfeeding

the educational group for subjective norms

at pre- and post-educational intervention
about father, mother-in-law and friends; but
there was a significant difference for mother
and medical staff, demonstrating that the
people close to the mother are important
to her breastfeeding behaviour. Thus, the
educational programmes should not only be
held for mothers but for family members,
especially those close to her. Engagement of
family members and health-care providers,
in addition to provision of individual support
in the problem-solving process, has been
assumed as a leading factor to improvement
in decision making and stress reduction
(Moattari et al, 2012). A study by StewartKnox et al (2003)in Northern Ireland also
supports the point that improper norms
make it more difficult for mothers to have
successful breastfeeding. Therefore, there
should be a social approach in educational
programmes. Bertini et al (2003) showed that
subjective norms such as fathers, friends
and medical staff s attitudes are effective
on breastfeeding commencement and its
continuation. It has also been found that
fathers and friends support, breastfeeding
acceptance as a social norm, attending prenatal
classes and postnatal support have been among
the most important factors for breastfeeding
commencement and continuation (MahonDaly et al, 2002). McInnes et al (2008)
also concluded in their study that mothers
tend to rate social support as more
important than health care services. Other
studies results are inconsistent with those
of the present study. Sweet et al (2009)
concluded in their study that: The active
and positive contribution that fathers
make towards pre-term breastfeeding should
282

Conclusion
Education based on the BASNEF model for
involving social norms in education and
enabling factors, rather than traditional
methods, plays an important role in
promoting the awareness of the subject
and improving families attitudes about
breastfeeding. Promoting positive attitudes
also increases the behavioural intentions and
change. Therefore, holding continuous and
model-based educational sessions in health
centres is necessary for mothers to be able to
BJM
successfully breastfeed.

Acknowledgment: The present article is extracted from

the masters thesis by Ms Nasrin Bahmani through a
research grant from the Research Office of Shiraz University
of Medical Sciences. We would like to thank the Labor
Department officials at Hafez and Shooshtari Hospitals.
The authors would also like to thank Dr Nasrin Shokrpour
at the Center for Development of Clinical Research of
Nemazee Hospital for editorial assistance.
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